Driving with Dementia
Driving is often inexorably equated with independence. The ability to pick up those car keys and go wherever you want, whenever you want, can be the ultimate freedom. Driving affects a person’s quality of life; transportation is necessary for obtaining food, medicine and clothing, for attending medical appointments and religious services, for staying involved in community activities and for visiting friends and family.
So when should an individual with dementia stop driving? And how does the driver and his/her family make that difficult decision?
NEW DRIVING GUIDELINES
The American Academy of Neurology met in Toronto in 2010 and offered new advice on driving for dementia patients. Based on their analysis of 422 studies on dementia and driving, researchers suggested new guidelines.
The Clinical Dementia Rating (CDR) scale, which is used by physicians to score memory, judgment and independent function, was found to be a good indicator of which drivers with dementia were most likely to fail a driving road test. Individuals who scored a 1 or above were deemed likely to fail a driver’s test. On the CDR, a score of 0 means no impairment, 0.5 indicates very mild dementia, 1.0 indicates mild dementia and 2 and 3 are moderate to severe dementia.
Making the driving safety decision isn’t as simple as a clinical test score, however. Studies showed that many individuals with a mild dementia diagnosis, perhaps as many as 76% of them in some of the studies examined, could still pass a driver’s test and drive safely. Given this ambiguity, researchers continued to search for additional guidelines for families.
The researchers identified warning signs for families. An accident in the last five years makes the driver more likely to have another collision. Drivers older than 70 with two or more traffic tickets in the last three years are at a higher risk for an accident. Driving less than 60 miles per week is often associated with unsafe driving. Drivers who impose their own restrictions, such as not driving at night or in the rain, may have impaired driving skills. Aggressive or impulsive drivers (traits associated with some forms and stages of dementia) may be unsafe drivers; this certainly can be true at any age. Caregivers noting any of these signs, in addition to a dementia diagnosis, may have greater reason for concern.
Caregiver evaluations of the safety risks of a driver with dementia correlated well with actual safety concerns, so caregivers should trust their instincts when they sense problems. Conversely, the personal assessment of the driver with dementia (“Of course I’m a safe driver”) correlated poorly with actual safety on the road, which may be partially explained by the impaired judgment often found in individuals with dementia.
To read the new guidelines for yourself, go to the April 12, 2010, online issue of Neurology (journal of the American Academy of Neurology) at http://bit.ly/drivingguidelines .
Since the individual driver with dementia is less likely to censor his or her own driving (although some do), the burden of keeping the driver and the public safe falls on the family and professional caregivers, including physicians.
THE DRIVING DISCUSSION
Since driving is such an emotional issue for the individual with dementia, how can you address the topic successfully? There is no easy answer. If the driver has an early dementia diagnosis and still has periods of clarity, discuss your safety concerns at those times. Would it be safe for his or her grandchildren to ride with the driver? Thinking about the safety of loved ones, and not just the driver’s safety, sometimes focuses the discussion less on dependence vs. independence and more on the safety of the driver, those grandchildren and neighborhood children on bikes, teenagers in other cars, etc. Physicians can assess vision, hearing and reflexes to advise patients and families about their effect on driving capabilities, which provides some objective considerations for discussion.
If your goal is to persuade someone to give up driving, be prepared to offer alternative methods of transportation. Learn about local transportation such as city busses or specialized senior transportation in the driver’s neighborhood, how to access that, and how much it costs. Have family and friends offer to drive the individual to religious services, the grocery store, the doctor, the mall or to visit friends and encourage everyone to do that with a smile on his/her face. Don’t make the individual ask for every ride. Instead, call and offer to take him or her along with you when you’re shopping or visiting. Come to visit (regularly) and offer to take your loved one out while you’re there. Make it fun to be together - - stop in the park and take a stroll or (if medically okay) stop for an ice cream cone. Find ways to get the individual who surrenders his keys wherever he/she needs to go and to prevent him or her from becoming isolated in the home.
Once the decision to stop driving has been agreed on, secure the vehicle and keys. If no one else in the home will be driving the car, remove it from the premises. Ask the driver if he or she wants to sell the car and bank the money or gift it to family, friends or charity. (If gifting to family or friends, get legal advice on how the gift might affect a subsequent Medicaid application or taxes – selling for fair market value is often a better idea.) Don’t leave the car and keys available as a temptation to drive “just this one time”. If another driver in the home uses the car, secure all keys when not in use and lock the garage and secure those keys. An individual with progressing dementia may forget that he/she no longer drives, or may regret having agreed to stop. Families with a car on the premises have occasionally resorted to disabling the vehicle to keep a driver with dementia safe.
If transportation will be a serious problem if the individual stops driving, it may be time to discuss a move to a senior residence, such as an assisted living facility, that has a bus or car and driver that residents can schedule for doctors’ appointments and shopping. Having more services available in the residence itself, such as meals and snacks, hair care and activities, may make driving less necessary and life more enjoyable.
MEDIATION CAN HELP
When the driver and family cannot agree on whether it is time to stop driving, sometimes mediation can help before things escalate too far. A professional mediator, with a good knowledge of dementia, aging issues and family interactions, can sometimes provide the professional, neutral approach that lets the older driver feel heard and respected. The discussion is no longer family members telling the driver what he or she must do; the discussion now becomes just that, a discussion of pros and cons that allows the driver to “save face” and reach his/her own decision about driving safety. Part of the mediation may include a negotiation in which family members agree to provide substitute transportation so that the individual with dementia doesn’t simply “give up” something of value; he or she gets something in return that will make the situation manageable. To learn more about mediation for seniors and families, please see http://www.e-seniorservices.com/aging-issues-mediation.html.
DRIVING EVALUATION PROGRAMS FOR DEMENTIA PATIENTS
Objective assessment, rather than families merely cajoling the driver to quit or arguing about how poor driving skills have become, can be invaluable in having the driving discussion. In the Dallas-Fort Worth, Texas, area, there are two rehabilitation hospitals with driving evaluation programs. If you are outside the DFW area, try searching rehabilitation and driving assessment or evaluation on the internet to find a program close to you.
In the DFW metroplex, both the Baylor Institute for Rehabilitation and Integra Hospital Plano offer driving evaluations. The Baylor program involves road testing in a dual-controlled car, while the Integra testing is done on a driving simulator. The driver’s doctor initiates contact with the evaluation programs by faxing in a referral to either program. The doctor receives a detailed written report of the evaluation findings which he or she will then share with the patient. Those two programs are described briefly below.
BAYLOR: The Baylor Institute for Rehabilitation (BIR), 909 N Washington in Dallas, offers their Adaptive Driving Program for adults concerned about their driving skills after experiencing a stroke, traumatic brain injury, dementia, vision impairment, amputation or other condition that might affect driving skills. The program includes a two-part driving evaluation (interview and in-vehicle exam). An individual is scheduled for evaluation at BIR only after his or her physician faxes a referral for a driving evaluation to Baylor at 214-820-8744.
The driving evaluation begins with a rehabilitation therapist asking questions of the driver before they enter a vehicle. The questions are designed to identify risk factors and problems that might affect driving skills. After the interview, the driver and a therapist enter a BIR vehicle in the parking lot. The therapist works with the driver in the parking lot area to test cognitive skills related to driving, reaction times and responses to directions from the therapist. From there, the driver and therapist conduct a “road test”, in a dual-control car (meaning the therapist can take over driving functions if needed), and the therapist evaluates the driver’s skills on the road.
At the end of the 3-hour evaluation, a written report of the therapist’s findings and recommendations is prepared and sent to the driver’s physician, where it can be shared with the driver.
If the therapist recommends additional driving instruction, BIR can offer that instruction to a driver in order to improve driving skills. When the BIR therapist finds the driver to be capable of driving, and if the driver must retest with the state to regain his/her license, the therapist can accompany the driver to the state testing facility.
Per a BIR representative, the average out-of-pocket cost to drivers for the evaluation is approximately $820.
For more info on the BIR program, contact Baylor at 214-820-9300.
INTEGRA: Integra Hospital, 2301 Marsh Lane, Plano, TX 75093, which specializes in rehabilitation services, also offers a driver evaluation program. Again, a driver is scheduled only after his/her physician faxes an order requesting a driving evaluation to Integra at 972-428-1742.
The Integra evaluation begins with the driver completing a written evaluation. If the driver passes the written exam, Integra therapists then evaluate the driver on a sophisticated driving simulator. The simulator permits the driver to”drive” in a variety of weather and traffic conditions. The equipment tests response time, vision and performance under varied driving conditions. At the conclusion of the evaluation, a brief summary of the results is given to the driver and a full report is sent to the referring physician, who can then share the detailed results with the driver. Integra does not conduct a road test, but uses its simulator to test driving skills.
If the evaluation indicates the driver might benefit from additional on-the-road monitored driving experience, the therapist may recommend that a family member or friend take the driver out for additional experience or that the driver contact a driving school for a few lessons (generally about $40/hour).
Integra staff reported to me that their driver’s evaluation is generally paid by the driver’s health care insurance, including Medicare. This may be different from the cost of the Baylor program because Baylor uses a road test in their evaluation, which may look more like a driving test than a medical assessment to insurers.
For more information on the Integra driver’s evaluation program, contact the program at 972-428-1750.
With both programs, if the driver is found to be unsafe and currently has a driver’s license, the driver’s physician may be required to report his or her evaluation of the driver’s capabilities to the state.
Dee Bergan, E-Senior Services